Inquest into the Death of Jesse Richard DELLAR

Summary : The deceased was a sensitive and complicated young man with a history of psychological disturbance due to various causes. He sought medical help for many years but struggled with bouts of depression and suicidal thoughts. He was 17 years of age at the time of his death.

The deceased spent four days in Albany Regional Hospital being treated before he ran away on the afternoon of 27 November 2010. He was found in a nearby park where he had hanged himself and died.

The focus of the inquest was primarily on how the deceased was able to leave the hospital, given the hospital staff were aware of his unstable state of mind and were meant to be supervising and observing him regularly. The inquest also explored what care is available in the South West for young people with mental health issues.

On 23 November 2010 the deceased was taken to the Emergency Department of the Albany Regional Hospital after he deliberately overdosed. He was admitted to Ward C, a general ward of the hospital under the care of a doctor. He was prescribed medication and placed on two hourly observations. He was referred to CAMHS and seen by a social worker on 24 November 2010 who arrange for the deceased to be seen by a psychiatrist on 25 November 2010.

The psychiatrist saw the deceased late on the afternoon of 25 November 2010 and gave a provisional diagnosis as suffering moderately severe depressive episode with symptoms of anxiety suggestive of co-morbid panic disorder. A proposed management plan was made for the deceased’s treatment and discharge plan.

On 26 November 2010 the deceased was observed to have been unsettled and talking loudly on his mobile phone. At about 11:00pm he was asked to cease using his mobile phone as it may disturb other patients. At that time he appeared to be settled and comfortable and was engaging with nursing staff. At approximately midnight the deceased rang his bell and informed nursing staff that he had attempted to hang himself in the bathroom with a shower cord. Nursing staff took this admission seriously. The on-call doctor was notified and nursing staff were advised to provide the deceased with medication and to closely monitor him. He was moved to a single room enabling closer observations to be kept.

The following morning the deceased appeared settled and was due to be reviewed by his doctor at about midday. He was asleep when the doctor came to his room so the doctor left, intending to return later.

In the early afternoon of 27 November 2010 the deceased had an argument with his mother and became aggressive towards her. He ran from the room. The deceased’s mother notified staff that the deceased had left the ward and that they had argued regarding his mobile phone bill. Police were dispatched to look for the deceased. The deceased was located hanging by a rope around his neck from a tree near a cycle path in Collingwood Park. Police attended the scene, cut the deceased down and waited for ambulance officers to arrive whereby they examined the deceased and declared him life extinct.

The Coroner commented that the Albany Hospital had implemented changes which would hopefully improve the care offered to young patients.

The Coroner found that the deceased died on 27 November 2010 as a result of ligature compression of the neck (hanging) and death arose by way of suicide.